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The Tonsils and Adenoids in

Pediatric Patients

Kent Andreas Khurniawan

FK UGM

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Introduction

1994 140,000 U.S. children under the age

of 15 had adenoidectoies and !"#,000 had

adenotonsillectoies$his is down fro a %ea& of o'er 1 illion

in the 19(0)s

$hese are the ost coon a*or surgical%rocedures in children.

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History

+elsus first descried tonsillecto- in 0 A./.aul of Aegina wrote his descri%tion in #!5 A./.

1"#( ilhel Me-er re%orts reo'al of 2adenoid'egetations3 through the nose with a ring &nife.

191( Sauel . +rowe %ulished his re%ort on1000 tonsillectoies, used +rowe/a'is outh

gagart of alde-er)s ring after the Geran

anatoist who descried the

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Immunology and Function

art of secondar- iune s-ste6o afferent l-%hatics

78%osed to ingested or ins%ired antigens %assedthrough the e%ithelial la-er

unologic structure is di'ided into 4co%artents: reticular cr-%t e%itheliu, e8tra

follicular area, antle ;one of the l-%hoidfollicle, and the gerinal center of the l-%hoidfollicle

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Merane cells and antigen %resentingcells are in'ol'ed in trans%ort of antigen

fro the surface to the l-%hoid follicleAntigen is %resented to $hel%er cells$hel%er cells induce < cells in gerinal

center to %roduce antiod-Secretor- gA is %riar- antiod- %roducedn'ol'ed in local iunit-

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Microbiology of

adenotonsillitisGrou% A etaheol-tic is ost recogni;ed

%athogen

Associated with a ris& of rheuatic fe'er

and gloerulone%hritis

Man- other organiss are in'ol'ed

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Most e%isodes of acute %har-ngitis and

acute tonsillitis are caused - 'iruses such

as the following: =S>

7%steinirus

+M>

?ther her%es 'iruses Adeno'irus

etc

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?f %articular i%ortance are etalactaase%roducing organiss li&e Sta%h-lococcus aureus,

Mora8ella catarrhalis, and =eo%hilus influen;ae.Most cases of acterial tonsillitis are caused -grou% A etaheol-tic Streptococcus pyogenes@GA

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Infectious Organisms

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Epidemiology

$onsillitis ost often occurs in childrenB howe'er,

the condition rarel- occurs in children -ounger

than ! -ears. $onsillitis caused - Streptococcus

s%ecies t-%icall- occurs in children aged 515

-ears, while 'iral tonsillitis is ore coon in

-ounger children.

eritonsillar ascess @$A usuall- occurs in

teens or -oung adults ut a- %resent earlier.

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Most %resenting s-%to : Sore throatSign wC +o%lications :

a. $risus. nailit- to swallow liDuid

c. nc. sali'ation or drolling

d. eritonsillar edea

e. /e'iation of U'ula

f. As-etr- C dis%lacent of soft %alate

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Upper AW Obstruction

Stridor

Air hunger

Ees%irator- distress

$o8ic a%%earance

+-anosis

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! suggesti"e #A$H

$onsillar swelling or e8udate

Swollen anterior cer'ical nodes

Fe'er " +

ac& of cough

Aged 5 H 15 -ears.

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Physical E&amination

h-sical e8aination in acute tonsillitis re'eals

fe'er and enlarged inflaed tonsils that a- ha'e

e8udates

Grou% A etaheol-tic Streptococcus pyogenes

and 7%stein

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+onsider infectious

ononucleosis due to 7

in an adolescent or -ounger

child with acute tonsillitis,%articularl- when it is

acco%anied - tender

cer'ical, a8illar-, andCor

inguinal nodesB

s%lenoegal-B se'ereletharg- and alaiseB and

lowgrade fe'er.

$onsillitis caused - 7%stein

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Adenotonsillar disease

Ma*or di'isions are: nfectionCinflaation

?structi'e6eo%las

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Acute adenoiditis

S-%tos include: urulent rhinorrhea

6asal ostruction Fe'er

Associated ?titis Media

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'ecurrent Acute Adenoiditis

4 or ore e%isodes of acute adenoiditis in a

# onth %eriod

Siilar %resentation as recurrent acuterhinosinusitis

n older children nasal endosco%- can hel%

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(hronic adenoiditis

S-%tos include: ersistent rhinorrhea

ostnasal dri% Malodorous reath

Associated otitis edia onths

$hin& of reflu8

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Acute Tonsillitis

Signs and s-%tos: Fe'er

Sore throat $ender cer'ical l-%hadeno%ath-

/-s%hagia

7r-theatous tonsils with e8udates

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'ecurrent Acute Tonsillitis

Sae signs and s-%tos as acute

?ccurring in 4( se%arate e%isodes %er -ear

5 e%isodes %er -ear for ! -ears

e%isodes %er -ear for -ears

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(hronic Tonsillitis

+hronic sore throat

Malodorous reath

resence of tonsilliths

eritonsillar er-thea

ersistent tender cer'ical l-%hadeno%ath-

asting at least onths

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Peritonsillar abscess

Ascess foration outside tonsillar ca%sule

Signs and s-%tos:

Fe'er Sore throat

/-s%hagiaCod-no%hagia

/rooling

$risus Unilateral swelling of soft %alateC%har-n8 with u'ula

de'iation

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Obstructi"e Adenoid

HyperplasiaSigns and S-%tos

?ligate outh reathing

=-%onasal 'oice Snoring and other signs of slee% disturance

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Obstructi"e Tonsillar

HyperplasiaSnoring and other s-%tos of slee%

disturance

Muffled 'oice/-s%hagia

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Lab Studies

$hroat cultures are the criterion standard for detecting

grou% A etaheol-tic Streptococcus pyogenes

@GA

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Imaging Studies Eoutine radiologic iaging is not useful in cases of acute

tonsillitis.

For %atients in who acute tonsillitis is sus%ected to ha'e

s%read to dee% nec& structures @ie, e-ond the fascial

%lanes of the oro%har-n8, radiologic iaging using %lain

fils of the lateral nec& or +$ scans with contrast is

warranted.

n cases of %eritonsillar ascess @$A, +$ scanning with

contrast is indicated in generalJ10 for unusual%resentations @eg, an inferior %ole ascess and for %atients

at high ris& for drainage %rocedures @eg, %atients with

coagulo%ath- or anesthetic ris&.

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Medication

$reatent of acute tonsillitis is largel- su%%orti'e and

focuses on aintaining adeDuate h-dration and caloric

inta&e and controlling %ain and fe'er.

nailit- to aintain adeDuate oral caloric and fluid inta&e

a- reDuire > h-dration, antiiotics, and %ain control.

=oe intra'enous thera%- under the su%er'ision of

Dualified hoe health %ro'iders or the inde%endent oral

inta&e ailit- of %atients ensures h-dration.

ntra'enous corticosteroids a- e adinistered to reduce%har-ngeal edea @effecti'eness LLL Safet- LLL

o;anges for significant throat %ain and discofort

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Medical Management

enicillin @Ao8icillin is first line treatent

Eecurrent or unres%onsi'e infections reDuire

treatent with etalactaase resistant antiioticssuch as +linda-cin

Augentin

enicillin %lus rifa%in

Adenotonsillar h-%er%lasia a- res%ond to one onth of

thera%- with etalactaase resistant antiiotics

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Adinistering oral %enicillin for 10 da-s is the est

treatent of acute GA

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?ther antiiotics %ro'en effecti'e for GA

adinistration.

+linda-cin is effecti'e e'en for organiss that are not

ra%idl- di'iding @7agle effect, which e8%lains its greatefficac- for GA

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Beta-lactamase resistance

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EeducedfreDuenc- dosing is recoended to

i%ro'e co%liance with edication regiens. A

consensus on the efficac- of such dosing has not-et een forulated.

Medications that are used to anage tonsillitis

include antiiotics, antiinflaator- agents @eg,

corticosteroids, anti%-retics and analgesics @eg,acetaino%hen, iu%rofen, and iunologic

agents @eg, gaa gloulin.

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Tonsillectomy

+urrent clinical indicators of AA?=6S: or ore infections %er -ear des%ite adeDuate

edical thera%- =-%ertro%h- causing dental alocclusion or

ad'ersel- affecting orofacial growthdocuented - orthodontist

=-%ertro%h- causing u%%er airwa- ostruction,se'ere d-s%hagia, slee% disorder,cardio%ulonar- co%lications

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eritonsillar ascess unres%onsi'e to edical

anageent and drainage docuented - surgeon,

unless surger- %erfored during acute stage

ersistent foul taste or reath due to chronic tonsillitis

not res%onsi'e to edical thera%-

+hronic or recurrent tonsillitis associated with

stre%tococcal carrier state and not res%onding to eta

lactaase resistant antiiotics Unilateral tonsil h-%ertro%h- %resued neo%lastic

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Adenoidectomy

+urrent clinical indicators fro AA?=6S: 4 or ore e%isodes of recurrent %urulent rhinorrhea in

%rior 1! onths in a child 1!. ?ne e%isode

docuented - intranasal e8aination or diagnosticiaging.

ersisting s-%tos of adenoiditis after ! courses ofantiiotic thera%-. ?ne course of antiiotics should ewith a etalactaase stale antiiotic for at least !wee&s.

Slee% disturance with nasal airwa- ostruction%ersisting for at least onths

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=-%onasal or h-%ernasal s%eech

?titis edia with effusion onths or second set of

tues

/ental alocclusion or orofacial growth disturance

docuented - orthodontist

+ardio%ulonar- co%lications including cor

%ulonale, %ulonar- h-%ertension, right 'entricular

h-%ertro%h- associated with u%%er airwa- ostruction

?titis edia with effusion o'er age 4

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urgical methods

Adenoidecto- Adenotoe

+urettes =eostasis with %ac&ing andCor electrocauter-

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$onsillecto- $onsillotoe

+old dissection with snare Mono%olarCi%olar electrocauter-

+?! or K$ laser

=eostasis with %ac&ing, electrocauter-,sutures

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Indications for Obser"ation

Age

?structi'e slee% a%nea

Significant associated edical %roles6eurological dela-

+raniofacial anoralities

i'ing a long distance fro the hos%italNuestionale caregi'er at hoe

Known coagulo%ath-

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Scarlet fever

Manifests as a generali;ed, non%ruritic, acular

er-theatous rash that is worse on the e8treities

and s%ares the face. $he classic strawerr- tongue

is right red and tender ecause of %a%illar-desDuaation. $he rash lasts u% to 1 wee& and is

acco%anied - fe'er and arthralgias. ndi'iduals

at ris& for this rash are those who do not ha'e

antito8in antiodies to the e8oto8in %roduced -GA

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Acute poststreptococcal

glomerulonephritis

?ccurs in 1015I of %har-ngitis cases that

are caused - the t-%e1! serot-%e. AG6

follows GA

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Septic arthritis

Eesults in a %ainful hot *oint that contains

fluid with acteria. Arthrocentesis is

diagnostic and %artiall- thera%eutic.$reatent with > antiiotics for # wee&s is

reDuired to %re'ent longter *oint

co%lications.